THE NEW INDIA ASSURANCE CO. LTD.

(Wholly owned by the Govt. of India)

THE NEW INDIA ASSURANCE CO. LTD.

REGISTERED & HEAD OFFICE:87,MAHATMA GANDHI ROAD,MUMBAI 400001.

GOOD HEALTH POLICY CERTIFICATE

Certificate No. 712500/GH/FEB2017/25119 Period of Insurance From 01/02/2017

To 31/01/2018
R P GANGADHARAN Card Number : 5291XXXXXXXX7211
OLD NO:A-90,NEW NO:16 Master Policy No. : 71250034162100000026
VENKATESAN STREET
PERIYAR NAGAR

CHENNAI 600082 Clause attached : GH 2013-OCT

Mobile No:9445394125 Email Id:rpgangadharan@yahoo.co.in Service Tax Registration : AAACN4165CST178
Personal Accident Mediclaim Section Hospital Cash Benefit Nomination Particulars for PA Coverage
Section
Name of the Insured Sum Premium + Sum Premium + Limit per Max. no. Name Relation
Person Insured Service Tax Insured Service Tax day (`) of days
(`In (`) (`In (`)
Lakhs) Lakhs)
R G ANANDHI 2 3202
R G VAISHNAVI 0.5 626
R G VISHNU ARAVIND 0.5 626
R P GANGADHARAN 2 5158
R P NAVAMANI 2 8532
Total Premium including 0 18144
Service Tax

Nomination for Certificate Name: Relation:

Holder for Mediclaim

Cumulative Bonus for Mediclaim

Name of the Insured DOB Customer % Applicable Effective date Pre-existing diseases/Disabilities
Person code S.I. excluded - refer Clause No.4.1(for
Mediclaim)
R G ANANDHI 01/06/1977 20170215633 0 0 Not Applicable
R G VAISHNAVI 03/07/1999 20170215634 0 0 Not Applicable
R G VISHNU ARAVIND 24/10/2005 20170215635 0 0 Not Applicable
R P GANGADHARAN 01/06/1968 20170215636 0 0 Not Applicable
R P NAVAMANI 15/08/1947 19990227240 50 200000 Not Applicable

Terms & Conditions forming part of this Policy No. 71250034162100000026 may be downloaded from our website,
newindia.co.in/citibank.

Notice or communication to be given in respect of claims to TPA

Name and Address of MD INDIA HEALTHCARE SERVICES(TPA)
TPA PVT.LTD.
MOUNT CASA BLANCA BUILDING,3RD FLOOR,
NO.260,ANNA SALAI,CHENNAI-600006.
Email Id citibank_chennai@mdindia.com
Contact TOLL FREE: 1800-233-1166
Details
FAX TOLL FREE: 1860-233-4449
PAN UAN: 1860-233-4446, 1860-233-4448
Website www.mdindiaonline.com

Signature Not
Verified
Digitally signed
by Srinivasan Document generated by null at 07/02/2017 05:00:07 Hours.
Vaideswaran Regd. & Head Office: New India Assurance Bldg., 87 M.G. Road, Fort, Mumbai - 400 001. TOLL FREE No. 1 800 209 1415.
Date: 2017.02.07
For 05:03:47
redressal of your grievance, if any,you may approach any one of the following offices- 1. Policy issuing office 2. Regional office 3. Head office.In case, you are not satisfied with
IST
our own grievance redressal mechanism; you may also approach Insurance Ombudsman. For details of our office addresses and addresses of office of Insurance Ombudsman, please
visit our website http://newindia.co.in.
 THE NEW INDIA ASSURANCE CO. LTD.
(Wholly owned by the Govt. of India)

This certificate is issued based on the application made by the Citibank Card Members / Account Holders in writing / over
internet / Phone in respect of self and/or family members and/or domestic employess such application shall be the basis of
this Contract of Insurance Coverage.
The benefits in respect of the within mentioned insured persons are subject to definitions,terms,conditions and exclusions
under the respective policies.
This policy is subject to Good Health Policy Clause GH 2013-OCT.
Address of the Policy Divisional Office : 712500 In witness whereof the undersinged being duly authorised
issuing Office II Floor, Mount Casa Blanca Building, by the Insurers and on behalf of the Insurers has (have)
No.260, Anna Salai,Chennai-600006 hereunder set his (their)hand(s) on this 01st day of February
2017.
Phone Numbers 044-23456824 /826 / 827
Fax 044-23456825
Email Id nia.gh712500@newindia.co.in
Website newindia.co.in/citibank

For The New India Assurance Company

Limited

N. JEYACHANDRAN
Senior Divisional Manager

Document generated by null at 07/02/2017 05:00:07 Hours.

Regd. & Head Office: New India Assurance Bldg., 87 M.G. Road, Fort, Mumbai - 400 001. TOLL FREE No. 1 800 209 1415.
For redressal of your grievance, if any,you may approach any one of the following offices- 1. Policy issuing office 2. Regional office 3. Head office.In case, you are not satisfied with
our own grievance redressal mechanism; you may also approach Insurance Ombudsman. For details of our office addresses and addresses of office of Insurance Ombudsman, please
visit our website http://newindia.co.in.
 THE NEW INDIA ASSURANCE CO. LTD.
(Wholly owned by the Govt. of India)

THE NEW INDIA ASSURANCE CO. LTD.

REGISTERED & HEAD OFFICE:87,MAHATMA GANDHI ROAD,MUMBAI 400001.

MEDICLAIM PREMIUM CERTIFICATE FOR THE PURPOSE OF DEDUCTION UNDER SECTION 80 D OF

INCOME TAX (AMENDMENT) ACT 1986
(in respect of self / spouse / dependent children / dependent parents only)

Insurer : CITIBANK DO (712500)

Office Code
Address : II FLOOR, MOUNT CASA BLANCA BUILDING,
NO. 260, ANNA SALAI, CHENNAI 600006
TAMIL NADU
Telephone : 044-23456824 / 826 / 827
Fax : 044-23456825
Policy : 71250034162100000026
Number

This is to certify that Mr./Mrs. R P GANGADHARAN has paid ` 18144 (Rupees Eighteen Thousand
One Hundred Forty-Four Only) towards premium for Mediclaim Insurance GH FEB2017 25119 for
the period 01/02/2017 to 31/01/2018.

(You are not eligible to claim Income Tax Deduction in the event of Cancellation of this
Certificate).

For The New India Assurance Company

Limited

N. JEYACHANDRAN
Senior Divisional Manager

Document generated by null at 07/02/2017 05:00:07 Hours.

Regd. & Head Office: New India Assurance Bldg., 87 M.G. Road, Fort, Mumbai - 400 001. TOLL FREE No. 1 800 209 1415.
For redressal of your grievance, if any,you may approach any one of the following offices- 1. Policy issuing office 2. Regional office 3. Head office.In case, you are not satisfied with
our own grievance redressal mechanism; you may also approach Insurance Ombudsman. For details of our office addresses and addresses of office of Insurance Ombudsman, please
visit our website http://newindia.co.in.